Physician Perceptions about Administration of Immunizations Outside of Physician Offices

Preventive Medicine 32, 255–261 (2001) doi:10.1006/pmed.2000.0801, available online at http://www.idealibrary.com on

Physician Perceptions about Administration of Immunizations Outside of Physician Offices1 George R. Bergus, M.D.,*,2 Michael E. Ernst, Pharm.D.,† and Bernard A. Sorofman, Ph.D.† *Department of Family Medicine, College of Medicine, and †Division of Clinical and Administrative Pharmacy, College of Pharmacy, University of Iowa, Iowa City, Iowa 52245 Published online January 26, 2001

Background. Expanding nonphysician participation in the administration of immunizations has been suggested as a means of increasing immunization rates. However, there is little information about physician interest in collaborating with nonphysicians to provide out-of-office immunizations. Methods. All active members of the Iowa Academy of Family Physicians were surveyed by mail. Physicians reported on their collaboration histories, their willingness to collaborate in the future, their concerns with collaboration, and whether they approved of their patients’ using nonphysicians for immunizations. Results. Of 898 eligible physicians, 476 (53%) returned questionnaires that were analyzed. Seventy-five percent (n ⴝ 357) of the physicians reported that they had voluntarily collaborated with a person outside their office to provide immunizations. Ninety-five percent (n ⴝ 452) of physicians indicated a willingness to collaborate in some form in the future. However, physicians had concerns about (a) being able to be kept informed about immunizations their patients receive outside of their offices, (b) adequate training of the nonphysician to administer immunizations and respond to complications of immunization, and (c) loss of preventive health opportunities if patients ceased coming to physicians for routine immunizations. Conclusion. The majority of family physicians have collaborated to deliver immunizations and indicate support for nonphysician participation. Almost all physicians would consider future collaborative arrangements although they have concerns about

1

This project was funded by grants from Family Health Foundation of the Iowa Academy of Family Physicians and the Iowa Pharmacy Association, both located in Des Moines, Iowa. 2 To whom requests for reprints should be addressed. Fax: (319) 384-7822. E-mail: [email protected].

record keeping and the safety of out-of-office immunization programs. 䉷 2001 American Health Foundation and Academic Press

Key Words: immunization; cooperative behavior; family practice; vaccination.

INTRODUCTION

Immunizations are an integral, but underused, component of preventive health care. A decade ago, Healthy People 2000 promulgated a national goal of reducing the incidence of vaccine-preventable diseases by increasing rates of immunizations [1]. Because of the effectiveness of immunization in decreasing morbidity and mortality, increasing immunization rates continues to be a goal of Healthy People 2010 [2]. While substantial expansion of coverage has been accomplished, immunization levels in the United States continue to be lower than those set by the federal government and national organizations [3–6]. This is particularly true for adults. The target for pneumococcal vaccinations set by Healthy People 2000 was for 60% of seniors to be vaccinated during their lifetime. In 1997, the last year for which published data are available, not one state had met this target and the national rate was 43% [2,3]. While this represents substantial improvement from the 1989 rate of 14%, it remains well below the target of 90% set for the year 2010 [7]. Therefore, further improvement in the delivery of immunizations to patients is necessary. One possible approach is expanding access to immunizations by increasing the number of sites where patients can obtain immunization. Studies have documented the positive effect of collaborative immunization programs outside of physician offices [8–13]. Programs using community health

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0091-7435/01 $35.00 Copyright 䉷 2001 by American Health Foundation and Academic Press All rights of reproduction in any form reserved.

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nurses, school-based nurses, or pharmacists have demonstrated increased immunization rates as have programs using community volunteers to advocate and administer vaccines. Out-of-office immunization programs are currently receiving some support from federal and state agencies. For example, Medicare now reimburses nonphysician providers for influenza and pneumonia immunizations administered to eligible seniors [14]. Collaborative immunization programs based outside of physician offices have been offered as one of several strategies to increase immunization rates [15]. However, there is little information describing the present level of physician collaboration with such programs or interest in future relationships. Thus, we were interested in detailing the level of support that family physicians in Iowa have for nonphysician administration of immunization, their present and future interest in collaborative relationships, and their primary concerns about these relationships. This information was collected because we considered it relevant to designing collaborative out-of-office programs for increasing immunization coverage. METHODS

A questionnaire was used to characterize physicians’ experiences, perceptions, and attitudes about immunization programs based outside of physician offices. Physicians were asked about collaborative experiences by asking them to identify health professionals they “have worked with or are currently working with” besides their office staff to deliver immunizations to their patients. Physicians identified these collaborative relationships by use of a checklist of different health professions and with an open-ended option so that nonlisted providers could be identified. Physicians were also asked about their willingness to enter into collaborative relationships with different types of providers and the qualifications they desired for each collaborator. Additionally, physicians were asked about whether they would support their patient’s decision to use an out-of-office nonphysician provider for immunizations. Physicians were separately asked about the use of community health nurses, school nurses, pharmacists, and dentists for immunizations and were individually queried about pediatric patients in three age groupings— birth to age 3 years, 3 years to school age, and school age—as well as adults. Responses to these questions were collected using 5-point Likert scales. Lastly, physicians were asked to complete an open ended question about their primary concerns with out-of-office administration of immunizations. Approval from the Human Subjects Committee at the University of Iowa was obtained for this research. The

survey was pilot tested by 9 family physicians and revised based on their feedback. The surveys were then mailed to all 923 active members of the Iowa Academy of Family Physicians. Nonresponders received two copies of the survey and a reminder postcard. Two questionnaires were returned as undeliverable and 23 physicians were excluded because they reported that they were not currently practicing in Iowa, not practicing at least 10 months a year, or were not seeing at least six patients on an average work day. Thus, there were 898 eligible physicians in the sample. The responses of 476 physicians (53% response rate) are available for this report. There were between 1 and 9 missing data elements (mean 3.1) for each of the questions related to past, present, and future collaboration. Missing numerical values on the surveys, other than demographics, were imputed using the multivariate normal procedure. We analyzed physicians’ concerns about collaboration by categorizing the first concern provided by each physician in response to the open-ended question into general thematic categories. Logistic regression was used to model physicians’ willingness to collaborate with any nonphysician health care professional while adjusting for physician age, gender, town size, whether physicians current receive information about out-of-office immunizations, and previous collaborative experience. Univariate and multivariate statistical analyses were performed using NCSS 2000 (NCSS Statistical Software, Kayesville, UT) and a P value less than 0.05 was considered significant. Town size was converted to an ordinal scale for the univariate analysis by placing the physician’s practice site into one of three population categories: ⱕ20,000, 20,001–100,00, and ⬎100,000. RESULTS

The mean age of the physician respondents was 46.1 years (SD 9.4 years) with a mean of 17.3 years (SD 10.0 years) since being licensed to practice. One hundred nine (23%) of the respondents were female. The majority (57%) of the physicians practiced in towns of 20,000 or less, 27% practiced in towns sized 20,001 to 100,000 and 16% physicians practiced in towns greater than 100,000. Nearly all respondents reported that they currently provided immunizations to adults (98%) and to children (92%). Three hundred fifty-seven (75%) of the physicians reported that they had experience collaborating with a person outside their offices to deliver immunizations. Physicians were most likely to have collaborated with a nurse (69%), a nurse practitioner (20%), a physician’s assistant (11%), a trained community volunteer (9%), and a pharmacist (8%). There was no association between collaborative experience and gender or physician

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FIG. 1. Association between collaborative experience and town size.

age. However, town size was significantly associated (P ⬍ 0.0001) with collaborative experience (Fig. 1). Physician Support of Alternative Sources of Immunization Three hundred fifteen (66%) of the physicians reported that their patients sometimes received immunizations at a site other than the physician’s office and 86 (18%) of the family physicians reported that their patients usually or always received immunizations at another site. There was a strong negative association (P ⬍0.001) between town size and use of alternative sites for immunization (Table 1). About 90% of physicians supported an adult patient’s use of community health departments to obtain influenza or pneumococcal immunization (Table 2). In comparison, approximately one-quarter of the physicians TABLE 1 Association between Town Size of Physicians’ Practices and the Reported Frequency with Which Patients Obtain Their Immunization from Another Source (␹ 2, P ⬍ 0.001) Use of nonphysicians for immunization

Town size of physician practice

Rarely or never

0–20,000 20,001–100,000 ⬎100,000

22 (8.1%) 25 (19.4%) 28 (37.3%)

Sometimes

Usually or always

Total

176 (64.7%) 96 (74.4%) 43 (57.3%)

74 (27.2%) 8 (6.2%) 4 (5.3%)

272 129 75

supported an adult’s use of a pharmacist for these immunizations and fewer supported the use of a dentist. Compared with physicians practicing in small towns, physicians practicing in cities were more likely to support the use of pharmacists (41% vs 27.6%) and dentists (26.8% vs 9.6%) for adult influenza immunization (P ⬍ 0.001 for each). There was a similar association between support for using one of these health professionals for pneumococal immunization and town size (data not shown, P ⬍ 0.001 for each). Town size was not associated with support for the use of community health departments or school nurses. Most physicians (90%) supported a child’s use of community health departments for routine childhood immunization. The level of support did not vary with the age of the child, community size, or physician gender. Two-thirds (67%) of physicians supported school-age children receiving their routine immunizations from school nurses. Less than 12% of physicians supported children using pharmacists and fewer still supported the use of dentists for routine childhood immunization. Access to Immunization Histories About one-third (38%) of physicians reported they usually or always received notification when an out-ofoffice provider immunized one of their patients. There was a strong negative association between town size and being informed (P ⬍ 0.0001). Forty-six percent of physicians practicing in towns of 20,000 or less reported

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TABLE 2 Number of Family Physicians (%) Reporting They Would Support Their Patient’s Use of an Alternate Provider for Routine Immunization (n ⫽ 476) Number of physicians (%) supporting a patient’s use of alternate provider of immunization

Child immunization Ages 0–3 Preschool School age Adult immunization Pneumococcal Influenza

Community health department

Nurse in school setting

Pharmacist

Dentist

430 (90%) 429 (90%) 426 (89%)

233 (49%) 249 (52%) 318 (67%)

42 (9%) 45 (9%) 56 (12%)

31 (7%) 32 (7%) 42 (9%)

426 (89%) 431 (91%)

231 (48.5%) 244 (51%)

111 (23%) 126 (26%)

68 (14%) 71 (15%)

that they always or usually were informed about these immunizations compared with only 11% of physicians practicing in towns greater than 100,000. Physicians with collaborative experience were also more likely to report that they usually or always receive this information than did their peers without this experience (43.1% vs 24.4%, P ⬍ 0.001). The association between town size and being kept informed remained statistically significant (P ⬍ 0.001) after adjustment for physicians’ collaborative experiences using a regression model. Ninety-nine percent of physicians desired to be informed about out-of-office immunizations their pediatric patients received and 97% of physicians desired this information about their adult patients. Four hundred seventy-four (99.6%) of the physicians felt it was important to have easy access to patients’ complete immunization records. Nearly all (99%) also agreed that it was important for their patients to have easy access to this information as well. However, less than half of the physicians (46%) felt that maintaining a centralized immunization registry should be a state government responsibility. This attitude did not vary with size of the community in which a physician practiced, whether the physician had collaborative experience, or whether the physician reported that he or she was usually or

always kept informed. However, female physicians were more supportive of a state-maintained registry than were their male peers (57% vs 43%, P ⫽ 0.013). Future Collaboration Nearly all (95%) physicians reported that they might consider some form of collaboration to provide out-ofoffice immunizations (Table 3). Most (92%) of the physicians reported that they would consider collaboration with a nurse practitioner and 89% would collaborate with a school or public health nurse. In contrast, 50% would consider collaboration with a pharmacist, 40% with a trained community volunteer, and 37% with a dentist. Most physicians willing to collaborate stated that the minimum qualifications for individuals involved in out-of-office immunization programs should include basic CPR certification and an immunization course certification. Logistic regression was used to model physicians’ willingness to collaborate with any type of health care professional with physician age, gender, whether physicians currently received information about out-of-office immunizations, and town size (Table 4). Town size, gender, being informed, and physician age were not associated with future willingness to collaborate. However,

TABLE 3 Required Qualifications of Alternate Providers of Immunizations Sought by Physicians Distribution (%) of physicians willing to collaborate by desired qualifications of collaborator

Provider Physician assistant Nurse practitioner School nurse Registered pharmacist Trained community volunteer Dentist

Would not collaborate 39 40 51 240 285 299

(8.2%) (8.4%) (10.7%) (50.4%) (59.9%) (62.8%)

CPR only 62 53 57 29 26 21

(14.2%) (12.2%) (13.4%) (12.3%) (13.6%) (11.9%)

Immunization certification course

CPR certified and immunization certification course

109 (24.9%) 113 (25.9%) 111 (26.1%) 71 (30.1%) 54 (28.3%) 64 (36.2%)

266 (60.9%) 270 (61.9%) 257 (60.5%) 136 (57.6%) 111 (58.1%) 92 (52.0%)

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TABLE 4 Modeling by Logistic Regression of Physicians’ Perceived Willingness to Collaborate in the Future to Provide Out-of-Office Immunizations Regression coefficient

SE

Odds ratio

Odds ratio 95 CI

P value

0.15 ⫺0.02 0.45

0.54 0.02 0.33

1.16 0.82 1.57

0.40–3.34 0.51–1.32 0.82–3.00

0.7836 0.4224 0.1754

⫺0.57

0.46

0.57

0.23–1.39

0.2151

1.59

0.45

4.90

2.04–11.82

0.0004

Gender Age, per 10 years Town size Physician routinely receives information about out-of-office immunizations Physician with collaborative experience with out-of-office immunizations

physicians with collaborative experience were more receptive to future collaborative arrangements than physicians without this experience (P ⬍ 0.001). Physicians were invited to comment on the most important issues they would want resolved before they would enter into a collaboration with nonphysicians for delivery of immunizations. Two hundred and ten (44%) shared their concerns: 59 physicians (28% of those stating concerns) were concerned primarily with being able to be kept informed about the immunizations of their patients; 27% (n ⫽ 57) were concerned about adequate training, skills, and knowledge of the nonphysician providers; 22% (n ⫽ 46) were concerned about nonphysicians being able to respond to complications of immunization, and 8% (n ⫽ 17) were concerned about the loss of preventive health opportunities if patients ceased coming to their physicians for immunizations. Other issues noted included liability coverage of nonphysicians, nonphysicians’ abilities to communicate with patients, supervision for the nonphysicians, and cost to the patient. DISCUSSION

Family physicians in Iowa have significant experience working with out-of-office immunization providers. Most family physicians reported collaborating with nurses in schools and community health centers although relatively few had experience working with nontraditional immunization providers such as pharmacists. Physicians also reported that their patients frequently obtained immunizations from an out-ofoffice source. This finding also suggests there is widespread collaboration between physicians and other health care providers because most nonphysicians, such as nurses and pharmacists, cannot legally prescribe immunizations in Iowa. Almost all physicians were receptive to collaboration with nurses and half of the physicians would consider future collaboration with a pharmacist. Family physicians practicing in small towns were

nearly 50% more likely to report collaborative experiences in providing out-of-office immunizations than their peers practicing in large cities. It seems unlikely that this difference is due to divergent attitudes toward collaboration because willingness to consider future collaborative relationships was not related to town size. An explanation consistent with previous research is that collaboration is more likely to develop when there is good communication between physicians and other health care professionals in a community [16,17] The association between town size and communication between health professions is suggested by the finding that family physicians in smaller towns were more likely to be kept informed about out-of-office immunizations regardless of whether physicians reported collaborative relationships. Family physicians’ most common concern about their involvement with out-of-office immunization programs was being kept informed about the immunizations their patients receive. How best to operationalize such a system remains uncertain from our survey. While nearly all physicians report that they wanted this information, a majority of the physicians do not favor the use of a state-maintained centralized immunization database. This attitude is not unique to Iowa family physicians [18]. Other concerns centered on the knowledge and skills of nonphysicians providing out-of-office immunizations and the ability of nonphysicians to respond to adverse immunization reactions. Therefore, it is not surprising that most physicians wanted collaborators to be certified in basic CPR as well as completing an immunization course. Physician approval of a patient’s use of out-of-office immunizations varied with town size, patient age, and type of immunization provider. These findings may have bearing on future immunization program development. This survey indicated strong support for immunization by community health center nurses. Thus, new out-of-office immunization programs involving these nonphysician providers are likely to be supported by family physicians. Generally, there was limited support

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for involving persons who traditionally have not provided immunizations: community volunteers, pharmacists, and dentists. However, because family physicians are more supportive of an adult’s use of one of these alternate providers compared with a child’s use, immunization programs involving nontraditional providers will be more accepted by physicians if programs target adult immunizations alone. These data have several limitations. First, while we desired to learn the collaborative experiences of physicians, we actually asked physicians about whether they had worked with individuals outside of their office to provide immunizations to their patients. Unlike some states, Iowa has no legal definition of collaborative practice agreements. Several different definitions of the term collaboration have been offered in the literature although most center on working together to achieve a common purpose [17,19,20]. Second, the data are by self-report and may be biased due to reliance on recall or by selection bias. However, the association between the use of out-of-office immunization providers and community size was also found in a statewide survey of primary care physicians and a national survey of pediatricians [21,22]. CONCLUSION

Family physicians, particularly those practicing in smaller communities, report extensive collaborative experience in providing out-of-office immunizations. These physicians also report that their patients frequently receive immunizations outside of physicians’ offices and, in general, are supportive of this practice. Nationally, out-of-office immunization programs may help expand immunization coverage and are currently being studied [15]. We suggest that family physicians will support these programs if the programs are carefully designed to keep physicians informed about immunizations administered to their patients and consistently employ out-of-office providers with adequate knowledge and skills. Despite having concerns about provision of out-of-office immunizations by nonphysicians, almost all family physicians in Iowa report that they are interested in considering future collaborative relationships. REFERENCES 1. Healthy People 2000 Priority Area Area 20: Immunization and Infectious Diseases. http://odphp.osophs.dhhs.gov/pubs/hp2000/ 20imm2.htm. Accessed on 05/20/00. 2. U.S. Department of Health and Human Services. Healthy People 2010 (Conference Edition). Vol. 1: Chap. 14: Immunization and infectious diseases. Washington, DC: January 2000. http:// www.health.gov/healthypeople/Document/pdf/Volume1/ 14Immunization.pdf. Accessed 05/10/00. 3. U.S. Department of Health and Human Services. Healthy People 2000 Progress Review. Clinical Preventive Services. http://

odphp.osophs.dhhs.gov/pubs/hp2000/PROGRVW/clinical/ january 1999 clinical preventi.htm. Accessed on 05/10/00. 4. Murphy TV, Pastor P, Turner SB, et al. Estimating immunization coverage from school-based childhood immunization records. Pediatr Infect Dis J 1995;14:561–7. 5. Mustin HD, Holt VL, Connell FA. Adequacy of well-child care and immunizations in US infants born in 1988. JAMA 1994; 272:1111–5. 6. Butler JC, Shapiro ED, Carlone GM. Pneumococcal vaccines: history, current status, and future directions. Am J Med 1999; 26;107(1A):69S–76S. 7. Rodgers DV, Strikas RA, Hardy AM, Park C, Zell ER, Williams WW. Influenza and pneumococcal vaccination in the elderly: results of the 1989 National Health Interview Survey. In: Program and abstracts of the 119th annual meeting of the American Public Health Association. Washington, DC: American Public Health Association, 1991 (abstract). 8. Grabenstein JD, Hartzema AG, Guess HA, Rittenhouse BE. Community pharmacists as immunization advocates: cost-effectiveness of a cue to influenza vaccination. Med Care 1992; 30: 503–13. 9. Spruill WJ, Cooper JW, Taylor WJR. Pharmacist-coordinated pneumonia and influenza vaccination program. Am J Hosp Pharm 1982; 39:1904. 10. Ernst ME, Chalstrom CV, Currie JD, Sorofman B. Implementation of a community pharmacy-based influenza vaccination program. J Am Pharm Assoc 1997; NS37:570–80. 11. Barnes K, Friedman SM, Brickner Namerow P, Honig J. Impact of community volunteers on immunization rates of children younger than 2 years. Arch Pediatr Adolesc Med 1999; 153:518–24. 12. Slifkin RT, Clark SJ, Strandhoy SE, Konrad TR. Public-sector immunization coverage in 11 states: the status of rural areas. J Rural Health 1997; 13:334–41. 13. Vaccine-preventable diseases: improving vaccination coverage in children, adolescents, and adults. A report on recommendations from the Task Force on Community Preventive Services. Morb Mortal Wkly Rep 1999 48(RR-8):1–15. 14. Health Care Financing Administration. Questions & Answers for the Medicare Influenza and Pneumococcal Vaccination Benefits Effective October. http://www.hcfa.gov/quality/3g4.htm. Accessed 09/06/00. 15. Centers for Disease Control and Prevention. Adult immunization programs in nontraditional settings: quality standards and guidance for program evaluation—a report of the National Vaccine Advisory Committee and use of standing orders programs to increase vaccination rates: recommendations of the Advisory Committee on Immunization Practices. Morb Mortal Wkly Rep 2000; 49 (RR-1): 1–13. 16. Walker R, Adam J. Collaborative relationships in general practice projects. Aust Health Rev 1998; 21:203–20. 17. Berkowitz B. Collaboration for health improvement: models for state, community, and academic partnerships. J Public Health Manag Pract 2000; 6:67–72. 18. Christakis DA, Stewart L, Bibus D, Stout JW, Zerr DM, MacDonald JK, Gale JL. Providers’ perceptions of an immunization registry. Am J Prev Med 1999;17:147–50.

PHYSICIAN PERCEPTIONS OF OUT-OF-OFFICE IMMUNIZATION PROGRAMS 19. Reynolds PP, Giardino A, Onady GM, Siegler EL. Collaboration in the preparation of the generalist physician. J Gen Intern Med 1994; 9(4, Suppl. 1):S55–63. 20. Hughes AM, Mackenzie CS. Components necessary in a successful nurse practitioner–physician collaborative practice. J Am Acad Nurse Pract 1990;2:54–7.

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21. Bordley WC, Freed GL, Garrett JM, Byrd CA, Meriwether R. Factors responsible for immunizations referrals to health departments in North Carolina. Pediatrics 1994;94:376–80. 22. Ruch-Ross HS, O’Connor KG. Immunization referral practices of pediatricians in the United States. Pediatrics 1994, 94(4, Pt. 1):508–13.